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Photographic 

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23  WEST  MAt.'<i  STREET 

WEBSTER,  NY    14580 

(716)  872-4503 


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CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICMH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  Canadian  de  microreproductions  historiques 


Technical  and  Bibliographic  Notas/Notas  tachniquaa  at  bibliographiquas 


Tha  lni;tituta  has  attamptad  to  obtain  tha  bast 
original  copy  avallabia  for  filming.  Faaturas  of  this 
copy  which  may  ba  bibliographically  uniqua, 
which  may  altar  any  of  vha  imagas  In  tha 
raproduction,  or  whish  may  significantly  changa 
the  usual  method  of  filming,  are  checked  below. 


L'Institut  a  microfilm^  la  mailleur  axamplaire 
qu'il  lui  a  it6  possible  de  se  procurer.  Les  details 
de  cet  exemplaira  qui  sont  peut-itre  uniques  du 
point  de  vua  bibliographiqua,  qui  peuvent  modifier 
una  image  reproduite,  ou  qui  peuvent  exiger  une 
modification  dans  la  mithoda  normale  de  filmage 
sont  indiquAs  ci-dessous. 


0    Coloured  covers/ 
Couverture  da  coulaur 


D 


Covers  damaged/ 
Couverture  endommagie 


Covers  restored  and/or  laminated/ 


I I    Couverture  rostaurte  et/ou  peiiiculie 


WJ 


n 


Cover  title  missing/ 


titre  de  couverture  manque 


I — I    Coloured  maps/ 


Cartes  giographiquas  en  couleur 


□    Coloured  ink  (i.e.  other  than  blue  or  black)/ 
Encre  de  couleur  (i.e.  autre  que  blaue  ou  noirei 

□    Coloured  plates  and/or  illustrations/ 
Planches  et/ou  illustrations  en  couleur 


n 


Bound  with  other  material/ 
Relit  avec  d'autras  documents 


Tight  binding  may  causa  shadows  or  distortion 
along  interior  margin/ 

La  re  liure  serrie  leut  causer  de  I'ombre  ou  de  la 
distorsion  to  long  de  la  marge  intArieure 

Blank  leaves  added  during  restoration  may 
appear  within  the  text.  Whenever  possible,  these 
have  been  omitted  from  filming/ 
II  se  peut  que  certaines  pages  blanches  ajouties 
lors  d'une  restauration  apparaissent  dans  le  texte, 
mais.  lorsque  cela  itait  possible,  ces  pages  n'ont 
pas  M  filmies. 

Additional  comments:/ 
Commentaires  suppltmentaires; 


□    Coiourv.d  pages/ 
Pages  de  couleur 

□    Pages  damaged/ 
Pages  endommagtes 

□    Pages  restored  and/or  laminated/ 
Pages  restaurtes  et/ou  pelliculdes 

0    Pages  discoloured,  stained  or  foxed/ 
Pages  dicolories.  tacheties  ou  piqudes 

□    Pages  detached/ 
Pages  ditachtes 

Showthrough/ 
Transparence 

Quality  of  prir 

Qualiti  inigale  de  I'impression 

Includes  supplementary  materii 
Comprend  du  materiel  supplementaire 

Only  edition  available/ 
Seule  Mition  disponible 


r~^  Showthrough/ 

I      I  Quality  of  print  varies/ 

r~n  Includes  supplementary  material/ 

r~l  Only  edition  available/ 


D 


Pages  wholly  or  partially  obscured  by  errata 
slips,  tissues,  etc.,  have  been  refilmed  to 
ensure  the  best  possible  image/ 
Les  pages  totalement  ou  partiellement 
obscurcies  par  un  feuillet  d'errata,  une  pelure, 
etc.,  ont  M  film^s  A  nouveau  de  fa^on  d 
obtenir  la  meilleure  image  possible. 


This  item  is  filmed  at  the  reduction  ratio  checked  below/ 

Ce  document  est  filmi  au  taux  de  reduction  indiqut  ci-dessous. 

10X  14X  18X  22X 


26X 


30X 


y 

12X 


16X 


20X 


24X 


28X 


32X 


The  copy  filmed  hare  has  been  reproduced  thanks 
to  the  generosity  of: 

Medical  Library 
McGill  University 
Montreal 

The  images  appearing  here  are  the  best  quality 
possible  considering  the  condition  and  legibility 
of  the  original  copy  and  in  keeping  with  the 
filming  contract  specifications. 


L'exemplaire  filmi  fut  reproduit  grAce  A  la 
g^n^rositi  de: 

Medical  Library 
McGill  University 
Montreal 

Les  images  suivantes  ont  Ati  reproduites  avec  le 
plus  grand  soin,  compte  tenu  de  la  condition  at 
de  la  netteti  de  I'exemplaire  filmi,  et  en 
conformity  avec  les  conditions  du  contrat  de 
filmage. 


Original  copies  in  printed  paper  covers  are  filmed 
beginning  with  the  front  cover  and  ending  on 
the  last  page  with  a  printed  or  illustrated  impres- 
sion, or  the  back  cover  when  appropriate.  All 
other  original  copies  are  filmed  beginning  on  the 
first  page  with  a  printed  or  illustrated  impres- 
sion, and  ending  on  the  last  page  with  a  printed 
or  illustrated  impression. 


The  last  recorded  frame  on  each  microfiche 
shall  contain  the  symbol  -^(meaning  "CON- 
TINUED"), or  the  symbol  y  (meaning  "END"), 
whichever  applies. 

Maps,  plates,  charts,  etc..  may  be  filmed  at 
different  reduction  ratios.  Those  too  large  to  be 
entirely  included  in  one  exposure  are  filmed 
beginning  in  the  upper  left  hand  corner,  left  to 
right  and  top  to  bottom,  as  many  frames  as 
required.  The  following  diagrams  illustrate  the 
method: 


Les  exemplaires  originaux  dont  la  couverture  en 
papier  est  imprimte  sont  filmte  en  commenpant 
par  le  premier  plat  et  en  terminant  soit  par  la 
derniAre  page  qui  comporte  une  empreinte 
d'Impression  ou  d'illustration.  soit  par  le  second 
plat,  salon  le  cas.  Tous  les  autres  exemplaires 
originaux  sont  filmte  en  conimenpant  par  la 
premlAre  page  qui  comporte  une  empreinta 
d'Impression  ou  d'illustration  et  en  terminant  par 
la  dernlAre  page  qui  comporte  une  telle 
empreinte. 

Un  des  symboles  suivants  apparaftra  sur  la 
derniAre  image  de  cheque  microfiche,  selon  le 
cas:  le  symbols  —^  signifie  "A  SUIVRE".  le 
symbols  V  signifie  "FIN  ". 

Les  cartes,  planches,  tableaux,  etc.,  peuvent  Atre 
fllmAs  A  des  taux  de  rAduction  diff Arents. 
Lorsque  le  document  est  trop  grand  pour  Atre 
reproduit  en  un  seul  clichA.  il  est  filmA  A  partir 
de  I'angle  supArieur  gauche,  de  gauche  A  droite, 
et  de  haut  en  bas.  en  prenant  le  nombre 
d'images  nAcessaire.  Les  diagrammes  suivants 
illustrent  la  mAthode. 


1  2  3 


1 

2 

3 

4 

5 

6 

OSLER  LIBRAaV, 

IdCGILL  UNIVERSITY. 

lilONTftEAL,  Canada 


?'>^ 


INTERNAL  MEDICINE  AS 
A  VOCATION 


INTERNAL  MEDICINE  AS 
A  VOCATION 


AN    ADDRESS 

.«   r,.KERAL  MEDICINE   AT  THE  NeW  YoRK 
3_E  -  --;;:;rr:  OCTOBER  1..H.  18. 


BY 


WILLIAM  OSLER,  M.  D. 

,.  ■      •    *;.,  Tnhna  Hcypkim  University 
Professor  of  Medinne  m  the  Johns  n<yp 


BBPBINTED  FROM 

THE  MEDICAL  NEWS 

NKW    YOBK.    NOVBMBKB   20TH,    1897 


h-<.]l 


coO 


^^ 


rwflW!«»***fc'**^"*'^ 


JOHN  MUBPHY  &  CO.,  PRINTERS, 
BALTIMORE. 


ADDRESS. 


IT  was  with  the  greatest  pleasure  that  I  accepted  an  invi- 
*  tation  to  say  a  few  words  before  this  section  of  the 
Academy  on  the  importance  of  internal  medicine  as  a  voca- 
tion, I  wish  there  were  another  term  to  designate  the  wide 
field  of  medical  practice  which  remains  after  the  separation 
of  surgery,  midwifery,  and  gynecology.  In  itself  it  is  not 
a  specialty,  but  embraces  at  least  half  a  dozen,  and  so  its 
cultivators  cannot  be  called  specialists,  but  bear  without 
reproach  the  good  old  name  physician,  in  contradistinction 
to  general  practitioners,  surgeons,  obstetricians,  and  gyne- 
cologists. I  have  heard  the  fear  expressed  that  in  this 
country  the  sphere  of  the  physician  proper  is  becoming  more 
and  more  restricted,  and  perhaps  this  is  true;  but  I  maintain 
(and  I  hope  to  convince  you)  that  the  opportunities  are  still 
great,  and  that  the  harvest  is  truly  plenteous,  while  the 
laborers,  though  not  few,  are  scarcely  sufficient  to  meet  the 
demand. 

At  the  outset  I  would  like  to  emphasize  the  fact  that 
the  student  of  internal  medicine  cannot  be  a  specialist.  The 
manifestations  of  almost  any  one  of  the  important  diseases 
in  the  course  of  a  few  years  will  "  box  the  compass"  of  the 
specialties.  Typhoid  fever,  for  example,  will  not  only  go 
the  rounds  of  those  embraced  in  medicine  proper,  but  will 
carry  its  student  far  afield  in  morbid  psychology,  and  some- 
times teach  him,  perhaps  at  the  cost  of  the  patient,  a  little 
surgery.      So,  too,  with  syphilis,  which  after  the  first   few 

3 


Internal  Medicine  as  a  Vocation. 


weeks  I  claim  us  a  medical  affection.  I  often  tell  my 
students  that  it  is  the  oidy  disease  which  they  require  to 
study  thoroughly.  Know  syphilis  in  all  its  manifestations 
and  relations,  and  what  remains  to  be  learned  will  not  stretch 
the  ])ia  mater  of  a  mogalocephalic  senior  student. 

Ea(;h  generation  has  to  grow  its  own  consultants,  Hos- 
sack,  Samuel  Mitchell,  Swett,  Alonzo  Clark,  Austin  Flint, 
Fordyce  Barker,  and  Alfred  Loom  is,  served  their  day  in 
this  city,  and  then  passed  on  into  silence.  Their  works 
remain  ;  but  enough  of  a  great  physician's  experience  dies 
with  him  to  justify  the  saying  "  there  is  no  wisdom  in  the 
grave."  The  author  of  "  Rab  and  His  Friends "  has  a 
couple  of  i)aragraphs  on  this  point  which  are  worth  quoting : 
"Much  that  made  such  a  man  what  the  community,  to  their 
highest  |)rofit,  found  him  to  be,  dies  with  him.  His  inborn 
gifts,  and  much  of  what  was  most  valuable  in  his  experience, 
were  necessarily  incommunicable  to  others ;  this  depending 
much  on  his  forgetting  the  process  by  which,  in  particular 
cases,  he  made  uj)  his  mind,  and  its  minute  successive 
steps  .  .  .  ,  but  mainly,  we  believe,  because  no  man  can 
explain  directly  to  another  man  hoio  he  does  any  one  prac- 
tical thing,  the  doing  of  which  he  himself  has  accomplished 
not  at  once  or  by  imitation,  or  by  teaching,  but  by  repeated 
personal  trials,  by  missing  much  before  ultimately  hitting." 

Wherewithal  shall  a  young  man  prepare  himself,  should 
the  ambition  arise  in  him  to  follow  in  the  footsteps  of  such 
a  teacher  as,  let  us  say,  the  late  Austin  Flint — the  young 
man  just  starting,  and  who  will  from  1915  to  1940  stand 
in  relation  to  the  profession  of  this  city  and  this  country 
as  did  Dr.  Flint  between  1861  and  the  time  of  his  death. 
We  will  assume  that  he  starts  with  equivalent  advantages, 
though  this  is  taking  a  great  deal  for  granted,  since  Austin 
Flint  had  a  strong  hereditary  bias  toward  medicine,  and 
early  in  life  fell  under  the  influence  of  remarkable  men 
whose  teachings  moldetl  his  thought  to  the  very  end.  We 
must  not  forget  that  Dr.  Flint  was  a  New  Englander,  and 


Internal  Medicine  an  a  VociiHon. 


of  the  same   type  of  mind  as   his  great  teachers — Jatues 
Jackson  and  Jacob  Bigelow. 

Our  future  consultant  has  just  left  the  hospital,  where, 
for  the  first  time  rcalizinj^  the  possibilities  of  his  profession, 
he  has  had  his  ambition  fired.  Shall  he  j;o  abroad?  It  is 
not  necessary.  The  man  whom  we  have  (iliosen  as  his 
exemplar  did  not,  but  fbimd  his  opportunities  in  country 
practice,  and  in  Buifalo  and  liouisville,  then  frontier  towns, 
and  had  a  national  reputation  before  he  reached  New  York. 
But  would  it  be  useful  to  him?  Undoubtedly.  He  will 
have  a  broader  foundation  on  which  to  build,  and  a  year 
or  two  in  the  laboratories  and  clinics  of  the  great  European 
cities  will  be  most  helpful.  To  walk  the  wards  of  Guy's 
or  St.  Bartholomew's,  to  see  the  work  at  the  St.  Louis  and 
at  the  Salp6tri6re,  to  have  put  in  a  few  (piiet  months  of 
study  at  one  of  the  German  university  towns  will  store  the 
young  man's  mind  with  priceless  treasures.  I  assume  that 
he  has  a  mind.  I  am  not  heedless  of  the  truth  of  Shake- 
speare's sharp  taunt, 

How  much  the  fool  that  hath  been  sent  to  Rome, 
Exceeds  the  fool  that  hath  been  kept  at  home. 

At  any  rate,  whether  he  goes  abroad  or  not,  let  him  early 
escape  from  the  besetting  sin  of  the  young  physician. 
Chauvinism^  that  intolerant  attitude  of  mind  which  brooks 
no  regard  for  anything  outside  his  own  circle  and  his  own 
school.  If  he  cannot  go  abroad  let  him  spend  part  of  his 
short  vacations  in  seeing  how  it  fares  with  the  brethren  in 
his  own  country.  Even  a  New  Yorker  could  learn  some- 
thing in  the  Massachusetts  General  and  the  Boston  City 
Hospitals.  A  trip  to  Philadelphia  would  be  most  helpful ; 
there  is  much  to  stimulate  the  mind  at  the  old  Pennsylvania 
Hospital  and  at  the  University,  and  he  would  be  none  the 
worse  for  a  few  weeks  spent  still  farther  south  on  the  banks 
of  the  Chesapeake.  The  all-important  matter  is  to  get  breadth 
of  view  as  early  as  possible,  and  this  is  difficult  without  travel. 


6 


Internal  Medicine  as  a  Vocation, 


I'oll  the  Huowasfiil  cotisniting  pliysiciuns  of  this  country 
to-day,  and  you  will  find  they  have  been  evolved  either 
from  j^eneral  practice  or  from  laboratory  and  clinical  work  ; 
many  of  the  most  prominent  having  risen  from  the  ranks  of 
general  prac^titioner.s.  !  once  hoard  an  eminent  consultant 
rise  in  wrath  because  some  one  had  made  a  remark  rcHecting 
upon  this  class.  He  declared  that  no  single  part  of  his 
professional  experience  had  l)een  of  such  value.  But  I  wish 
to  speak  here  of  the  training  of  men  who  start  with  the 
object  of  becoming  pure  physicians.  From  the  vantage 
ground  of  more  than  forty  years  of  hard  work,  Sir  Andrew 
Clark  told  me  that  he  had  striven  ten  years  for  bread,  ten 
years  for  bread  and  butter,  and  twenty  years  for  cakes  and 
ale;  and  this  is  really  a  very  good  partition  of  the  life  of 
the  student  of  internal  medicine,  of  some  at  least,  since  all 
do  not  reach  the  last  stage. 

It  is  high  time  we  had  our  young  Lydgate  started.'  If 
he  has  shown  any  signs  of  nous  during  his  student  and 
hospital  days  a  dispensary  assistantship  should  be  available ; 
anything  should  be  acceptable  which  brings  him  into  con- 
tact with  patients.  By  all  means,  if  possible,  let  him  be 
a  pluralist,  and — as  he  values  his  future  life — let  him  not 
get  early  entangled  in  the  meshes  of  specialism.  Once 
established  as  a  clinical  assistant  he  can  begin  his  education, 
and  nowadays  this  is  a  very  cora})licated  matter.  There  are 
three  lines  of  work  which  he  may  follow,  all  of  the  most 
intense  interest,  all  of  the  greatest  value  to  him — chemistry, 
physiology,  and  morbid  anatomy.  Professional  chemists 
look  askance  at  physiological  chemistry,  and  physiological 
chemists  criticize  pretty  sharply  the  work  of  some  clinical 
chemists,  but  there  can  be  no  doubt  of  the  value  to  the 
physician  of  a  very  thorough  training  in  methods  and  ways 


•This  well-drawn  character  in  George  Eliot's  " Middlemarch "  may  be 
studied  with  advantage  by  the  physician  ;  one  of  the  most  important 
lessons  to  be  gathered  from  it  is — marry  the  right  woman  I 


Inieiiial  Medicine  as  a  Vocation. 


of  organic  (ilieraiHtry.  We  sorely  want,  in  this  country, 
men  of  this  line  cf  training,  and  the  outlook  for  them  has 
never  before  been  so  bright.  If  at  the  start  he  has  not 
had  a  good  chemical  training,  the  other  lines  should  be 
more  closely  followed. 

Physiology,  which  for  him  will  mean  very  largely  experi- 
mental therapeutics  and  experimental  pathology,  will  open 
a  wider  view  and  render  possible  a  deeper  grasp  of  the 
problems  of  disease.  To  Traube  and  men  of  his  stamp,  the 
physiological  clinicians,  this  generation  owes  much  more  than 
to  the  chemical  or  poat-morteni-voom  group.  The  training 
is  more  difficult  to  get,  and  nowadays  when  physiology  is 
cultivated  as  a  specialty  few  physicians  will  graduate  into 
clinical  medicine  directly  from  the  laboratory.  On  the  other 
hand,  the  opportunities  for  work  are  now  more  numerous, 
and  the  training  which  a  young  fellow  gets  in  a  laboratory 
controlled  by  a  pure  physiologist  will  help  to  give  that  scien- 
tific impress,  which  is  only  enduring  when  early  received. 
A  thorough  chemical  training  and  a  complete  equipment  in 
methods  of  experimental  research  are  less  often  met  with 
in  the  clinical  physician  than  a  good  practical  knowledge 
of  morbid  anatomy ;  and,  if  our  prospective  consultant  has 
to  limit  his  work,  chemistry  and  physiology  should  yield  to 
the  claims  of  the  dead-house.  In  this  dry-bread  period  he 
should  see  autopsies  daily,  if  possible.  Successful  knowledge 
of  the  infinite  variations  of  disease  can  only  be  obtained  by 
a  prolonged  study  of  morbid  anatomy.  Of  special  value  in 
training  the  physician  in  diagnosis,  it  also  enables  him  to 
correct  his  mistakes,  and,  if  he  reads  its  lessons  aright,  it 
may  serve  to  keep  him  humble. 

This  is,  of  course,  a  very  full  programme,  but  in  ten  years 
a  bright  man  with  what  Sydenham  calls  "the  ancient  and 
serious  diligence  of  Hippocrates  "  will  pick  up  a  very  fair 
education,  and  will  be  fit  to  pass  from  the  dispensary  to 
the  wards.  If  he  cannot  go  abroad  after  his  hospital  term, 
let  it  be  an  incentive  to  save  money,  and  with  the   first 


8 


Internal  Medidne  as  a  Vocation. 


1600  let  him  take  a  summer  semester  in  Germany,  working 
quietly  at  one  of  the  smaller  places.  Another  year  spend 
three  months  or  longer  in  Paris.  Lay  schemes  in  advance, 
and  it  is  surprising  how  often  the  circumstances  fit  in  with 
them.  How  shall  he  live  meanwhile?  On  crumbs— on 
pickings  obtained  from  men  in  the  cakes-and-ale  stage  (who 
always  can  put  paying  work  into  the  hands  of  young  men), 
and  on  fees  from  classes,  journal  work,  private  instruction, 
and  from  work  in  the  schools.  Any  sort  of  medical  ])ractice 
should  be  taken,  but  with  caution — too  much  of  it  early  may 
prove  a  good  man's  ruin.  He  cannot  expect  to  do  more 
than  just  eke  out  a  living.  He  must  put  his  emotions  on 
ice  :  there  must  be  no  "  Amaryllis  in  the  shade,"  and  he 
must  beware  the  tangles  of  "  Nesera's  hair."  Success  during 
the  firsi:  ten  years  means  endurance  and  perseverance ;  all 
things  come  to  him  who  has  learned  to  labor  and  wait,  who 
hides  his  time  "  ohne  hast,  aber  ohne  rast,"  whose  talent 
develops  "in  der  Stille,"  in  the  quiet  fruitful  years  of 
urselfish  devoted  work.  A  few  words  in  addition  about  this 
ury-bvpad  decade.  He  should  stick  closely  to  the  dispen- 
saries. A  first-class  reputation  may  be  built  up  in  them. 
Bryom  Pramwell's  "Atlas  of  Medicine"  largely  represents 
his  work  while  an  assistant  physician  to  the  Royal  Infirm- 
a'-y,  Edinburgh.  Many  of  the  best-known  men  in  London 
serve  ten,  fifteen,  or  even  twenty  years  in  the  out-patient 
departments  before  getting  Vv-ards.  Lauder  Bruuton  has  only 
recently  obtained  his  full  physicianship  at  St.  Bartholomew's 
after  a  service  of  more  than  twenty  years  in  the  out-patient 
department.  During  this  period  let  him  not  lose  the  sub- 
stance of  ultimate  success  in  grasping  at  the  shadow  of 
prfccJf  at  oppi.  rtunity.  Time  is  now  his  money,  and  he  must 
not  barter  a\/ay  too  much  of  it  in  profitless  work — profitless 
so  far  as  his  education  is  conr^erned,  though  it  may  mean 
ready  cash.  Too  many  quiz  classes  or  too  much  journal  work 
has  ruined  many  a  promising  clinical  physician.  While  the 
Pythagorean  silence  of  neaily  seven  years,  which  the  great 


•'      .    % 


Internal  Medicine  as  a  Vocation. 


Louis  followed  (and  broke  to  hurst  into  a  full-blown  repu- 
tation) cannot  be  enjoined,  the  young  physician  should  be 
careful  what  and  how  he  writes.  Let  him  take  heed  to  his 
education,  and  hi?  reputation  will  take  care  of  itself,  and  in 
a  development  under  the  guidance  of  seniors  he  will  find 
plenty  of  material  ^or  papers  before  medical  societies  and 
for  publication  in  scientific  journals. 

I  would  like  to  add  here  a  few  words  on  the  question  of 
clinical  instruction,  as  with  the  great  prospective  increase  of 
it  in  our  schools  there  will  be  many  chances  of  employment 
for  young  physicians  who  wish  to  follow  medicine  proper 
as  a  vocation.  To-day  this  serious  problem  confronts  the 
professors  in  many  of  our  schools — how  to  teach  practical 
medicine  to  the  large  classes;  how  to  give  them  protracted 
and  systematic  ward  instruction?  I  know  of  no  teacher  in 
the  country  who  controls  enough  clinical  material  for  the 
instruction  of  classes  of  say  200  men  during  the  third  and 
fourth  years.  It  seems  to  me  there  are  two  plans  open  to 
the  schools  :  The  first  is  to  utilize  dispensaries  for  clinical 
instruction  much  more  than  is  at  present  the  rule.  For  this 
purpose  a  teaching-room  for  a  class  of  twenty-five  or  thirty 
students  immediately  adjoining  the  dispensary  is  essential. 
For  instruction  in  physical  diagnosis,  for  the  objective  teach- 
ing of  disease,  and  for  the  instruction  of  students  in  the  use 
of  their  senses,  such  an  arrangement  is  invaluable.  There 
are  hundreds  of  dispensaries  in  which  this  plan  is  feasible, 
and  in  which  the  material  now  is  not  properly  worked  up 
because  of  the  lack  of  this  very  stimulus.  In  the  second 
place,  I  feel  sure  that  ultimately,  we  shall  develop  a  system 
of  extra-mural  teaching  similar  to  that  which  has  been  so 
success  1  in  Edinburgh  ;  and  this  will  give  employment  to 
a  large  number  of  the  younger  men.  At  any  large  university 
school  of  r  juicine  there  might  be  four  or  five  extra-mural 
teachers  of  medicine,  selected  from  men  who  could  show 
that  they  were  fully  qualified  to  teach,  and  that  they  had 
a  sufficient  number  of  beds  at  their  command,  with  proper 


10 


Internal  Medicine  as  a  Vocation. 


equipment  for  clinical  work.  At  Edinburgh  there  are  eight 
extra-mural  teachers  of  medicine  whose  courses  qualify  the 
student  to  present  himself  for  examination  either  before  the 
Royal  Colleges  or  the  University.  If  we  ever  are  to  give 
our  third  and  fourth  year  students  protracted  and  complete 
courses  in  physical  diagnosis  and  clinical  medicine,  extending 
throughout  the  session,  and  not  in  classes  of  a  brief  period  of 
six  weeks'  duration,  I  am  confident  that  the  number  of  men 
engaged  in  teaching  must  be  greatly  increased. 

Ten  years'  hard   work    tells  with  colleagues  and   friends 
in  the  profession,  and  with  enlarged  clinical    facilities  the 
physician  enters  upon  the  second,  or  bread-and-butter  period. 
This,  to  most  men,  is  the  great  trial,  since  the  risks  are 
greater,  and  many  now  drop  out  of  the  race,  wearied  at  the 
length  of  the  way  and  drift  into  specialism  or  general  prac- 
tice.    The  physician  develops  more  slowly  than  the  surgeon, 
and  success  comes  later.     There  are  surgeons  at  forty  years 
in  full  practice  and  at  the  very  top  of  the  wave,  a  time  at 
which  the  physician  is  only  preparing  to  reap  the  harvest 
of  years  of  patient  toil.     The  surgeon  must  have  hands,  and 
better,  young  hands.     He  should  have  a  head,  too,  but  this 
does  not  seem  so  essential  to  success,  and  he  cannot  have  an 
old  head  with  young  hands.     At  the  end  of  twenty  years, 
when  about  forty-five,  our  Lydgate  should  have  a  first-class 
reputation  in  the  profession,  and  a  large  circle  of  friends  and 
students.     He  will  probably  have  precious  little  capital  in 
the  bank,  but  a  very  large  accumulation  of  interest-bearing 
funds  in  his  brain-pan.     He  has  gathered  a  stock  of  special 
knowledge  which  his  friends  in  the  profession  appreciate, 
and  they  begin   to  seek  his  counsel   in  doubtful  cases,  and 
gradually  le;u-n   to  lean   upon   hira  in  times  of  trial.     He 
may  awake  some  day,  perhaps,  quite  suddenly,  to  find  that 
twenty  years  of  quiet  work,  done  for  the  love  of  it,  has  a 
very  solid  value. 

The  environment  of  a  large  city  is  not  necessary  to  the 
growth  of  a  good  clinical  physician.     Even  in  small  towns 


Internal  Medicine  as  a  Vocation. 


11 


m 


a  man  can,  if  he  has  it  in  him,  become  well  versed  in 
methods  of  work,  and  with  the  assistance  of  an  occasional 
visit  to  some  medical  centre  he  can  become  an  expert  diag- 
nostician and  reach  a  position  of  dignity  and  worth  in  the 
community  in  which  he  lives.  I  wish  to  plead  particularly 
for  the  wasted  opportunities  in  the  smaller  hospitals  of  oui- 
large  cities,  and  in  those  of  more  moderate  size.  There  are 
in  this  State  a  score  or  more  of  hospitals  with  from  thirty 
to  fifty  medical  beds,  offering  splendid  material  for  good  men 
on  which  to  build  reputations.  Take,  for  example,  the  town 
of  Thelma,  which  I  know  well,  to  which  young  Rondibilis 
a  recent  resident  at  the  Hotel  Dieu,  has  just  gone.  He  wrote 
asking  me  for  a  letter  of  advice,  from  which  I  take  the 
liberty  of  extracting  one  or  two  paragraphs : 

"Your  training  warrants  a  high  aim.  Say  to  those  who 
ask,  that  you  intend  to  practice  medicine  only,  and  will  not 
take  surgical  or  midwifery  cases.  X.  has  promised  that  you 
may  help  in  the  disjiensary,  and  as  you  can  count  blood  and 
percuss  a  chest  you  will  be  useful  to  him  in  the  wards, 
which,  by  the  way,  he  now  rarely  visits.  Be  careful  with' 
the  house  physicians,  and  if  you  teach  them  anything  do  it 
gently,  and  never  crow  when  you  are  right.  The  crow  of 
the  young  rooster  before  his  spurs  are  on  always  jars  and 
antagonizes.  Get  your  own  little  clinical  laboratory  in  order. 
Old  Dr.  Rolando  will  be  sure  to  visit  you,  and  bear  with 
him  as  he  tells  you  how  he  can  tell  casts  from  the  ascending 
limb  of  the  loop  of  Henle.  He  was  once  as  you  are  now, 
a  modern,  but  he  crawled  up  the  bank  twenty  years  ago  • 
the  stream  has  left  him  there,  but  he  does  not  know  it! 
He  means  to  impress  you ;  be  civil  and  show  him  the  new 
Nissl-stain  preparations,  and  you  will  have  him  as  a  warm 
friend.  His  good  heart  has  kept  him  with  a  large  general 
practice,  and  he  can  throw  post-mortevis  in  your  way,  and 
may  send  for  you  to  sit  up  with  his  rich  patients.  If  Y. 
asks  you  to  help  in  the  teaching,  jump  at  the  chance.  The 
school  is  not  what  you  might  wish,  but   the  men   are  in 


12 


Internal  Medicine  as  a  Vocation. 


earnest,  and  a  clinical  microscopy-class  or  a  voluntary  ward- 
class,  with  Y's.  cases,  will  put  you  on  the  first  rung  of  the 
ladder.  Yes,  join  both  the  city  and  the  county  society,  and 
never  miss  a  meeting.  Keep  your  mouth  shut,  too,  for  a 
few  years,  particularly  in  discussions. 

"  Foote's  (Philadelphia)  is  the  catalogue  to  which  I 
referred.  Let  the  old  men  read  new  books ;  you  read  the 
journals  and  the  old  books.  Study  Laennec  this  winter; 
Forbes'  *  Translation '  can  be  cheaply  obtained,  but  it  will 
help  to  keep  up  your  French  to  read  it  in  the  original. 
The  old  Sydenham  Society  editions  of  the  Greek  writers  and 
of  Sydenham  are  easily  got  and  are  really  very  helpful.  As 
a  teacher  you  can  never  get  orientirt  without  a  knowledge 
of  the  Fathers,  ancient  and  modern.  And  do  not  forget, 
above  all  things,  the  famous  advice  to  Backraore,  to  whom, 
when  he  first  began  the  study  of  physic,  and  asked  what 
books  he  should  read,  Sydenham  replied,  '  Don  Quixote,* 
meaning  thereby,  as  I  take  it,  that  the  only  book  of  physic 
suitable  for  permanent  reading  is  the  book  of  Nature." 

A  young  fellow  with  staying  powers  who  avoids  entangle- 
ments, may  look  forward  in  twenty  years  to  a  good  consulta- 
tion practice  in  any  town  of  40,000  to  50,000  inhabitants. 
Some  such  man,  perhaps,  in  a  town  far  distant,  taking  care 
of  his  education,  and  not  of  his  bank  book,  may  be  the  Austin 
Flint  of  New  York  in  1930. 

''  Many  are  called,  but  few  are  chosen,"  and  of  the  many 
who  start  out  with  high  aims,  few  see  the  goal.  Even  when 
reached  the  final  period  of  "cakes  and  ale"  has  serious 
drawbacks.  There  are  two  groups  of  consultants,  the  intra- 
and  the  extra-professional ;  the  one  gets  work  through  his 
colleagues,  the  other,  having  outgrown  the  narrow  limits  of 
professional  reputation,  is  at  the  mercy  of  the  profanum 
vulgus.  Then  for  him  "farewell  the  tranquil  mind,  fare- 
well content."  His  life  becomes  an  incessant  struggle,  and 
between  the  attempt  to  carry  on  an  exhausting  and  irk- 
some practice,  and  to  keep  abreast  with  young  fellows  still 


Internal  Medicine  as  a  Vocation. 


13 


! 


in  the  bread-and-butter  stage,  the  consultant  at  this  period 
is  worthy  of  our  sincerest  sympathy. 

One  thing  raay  save  him.  It  was  the  wish  of  Walter 
•Savage  Landor  always  to  walk  with  Epicurus  on  the  right 
hand  and  Epictetus  on  the  left,  and  I  would  urge  the  clinical 
physician,  as  he  travels  farther  from  the  East,  to  look  well 
to  his  companions — to  see  that  they  are  not  of  his  own  age 
and  generation.  He  must  walk  with  the  "boys,"  else  he  is 
lost,  irrevocably  lost ;  not  all  at  once,  but  by  easy  grades, 
and  every  one  perceives  his  ruin  before  he,  "good,  easy  man," 
is  aware  of  it.  I  would  not  have  him  a  basil  plant,  to  feed 
on  the  brains  of  the  bright  young  fellows  who  follow  the 
great  wheel  uphill,  but  to  keep  his  mind  receptive,  plastic, 
and  impressionable  he  must  travel  with  the  men  who  are 
doing  the  work  of  the  world,  the  men  between  the  ages  of 
twenty-five  and  forty. 

In  the  life  of  every  successful  physician  there  comes  the 
temptation  to  toy  with  the  Delilah  of  the  press — daily  and 
otherwise.  There  are  times  when  she  may  be  courted  with 
satisfaction,  but  beware  !  sooner  or  later  she  is  sure  to  play 
the  harlot,  and  has  left  many  a  man  shorn  of  his  strength, 
viz.,  the  confidence  of  his  professional  brethren.  Not  alto- 
gether with  justice  have  some  notable  members  of  our  pro- 
fession labored  under  the  accusation  of  pandering  too  much 
to  the  public.  When  a  man  reaches  the  climacteric,  and  has 
long  passed  beyond  the  professional  stage  of  his  reputation, 
we  who  are  still  "  in  the  ring  "  must  exercise  a  good  deal 
of  charity,  and  discount  largely  the  on  dits  which  indiscreet 
friends  circulate.  It  cannot  be  denied  that  in  dealings  with 
the  public  just  a  little  touch  of  humbug  is  immensely 
effective,  but  it  is  not  necessary.  In  a  large  city  there  were 
three  eminent  consultants  of  world-wide  reputation ;  one  was 
said  to  be  a  good  physician  but  no  humbug,  the  second  was  no 
physician  but  a  great  luimbug,  the  third  was  a  great  physician 
and  a  great  humbug.  The  first  achieved  the  greatest  success, 
professional  and  socia,.,  possibly  not  financial. 


14 


Internal  Medicine  as  a  Vocation. 


While  living  laborious  days,  happy  in  his  work,  happy 
in  the  growing  recognition  which  he  is  receiving  from  his 
colleagues,  no  shadow  of  doubt  haunts  the  mind  of  the 
young  physician,  other  than  the  fear  of  failure ;  but  I  warn 
him  to  cherish  the  days  of  his  freedom,  the  days  when  he 
can  follow  his  bent,  untrammeled,  undisturbed,  and  not  as 
yet  in  the  coils  of  the  octopus.  In  a  play  of  Oscar  Wilde's 
one  of  the  characters  remarks,  "there  are  only  two  great 
tragedies  in  life,  not  getting  what  you  want — and  getting 
it ! "  and  I  have  known  consultants  whose  treadmill  life 
illustrated  the  bitterness  of  this  mot,  and  whose  great  success 
at  sixty  did  not  bring  the  comfort  they  had  anticipated  at 
forty.  The  mournful  echo  of  the  words  of  the  preacher 
rings  in  their  ears,  words  which  I  not  long  ago  heard  quoted 
with  deep  feeling  by  a  distinguished  physician,  "  Better  is 
a  handful  with  quietness  than  both  hands  full  with  travail 
and  vexation  of  spirit." 


I 


